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Snooping On the X-ray Tech: A Patient’s Dilemma

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(Image: iStockphoto)

I found myself in the hospital recently, watching my 11-year-old son get an X-ray for an arm he broke after a fall from his skateboard. As the technician positioned his arm on a table beneath the X-ray machine, she directed me to stand in the corner of the room, behind a protective window, so I wouldn't be exposed to the radiation.

The computer that ran the machine happened to be in the same corner, and, being curious, I read what was on the screen. The monitor showed my son's name, date of birth and other basic info – that all looked good. But it also said it was set to do an X-ray on a moderately sized adult. That didn't sound right. My boy only weighs about 80 pounds!

That’s where I faced a dilemma that I’m sure is quite familiar to anyone who has been a patient or watched a loved one undergoing medical treatment: Should I question the X-ray technician, or should I keep my mouth shut?

You can probably guess what I did. I didn’t want my son exposed to too much radiation, and I also wanted to be sure the X-ray was done correctly, so I pointed out the apparent discrepancy to the X-ray technician.

You can probably guess how she responded. It chapped her hide. “The machine’s setting is fine!” she said, clearly irritated. “I do this all day long. I know what I’m doing.”

I don’t doubt that she was correct. I’m sure she knows her machine, and that the setting was just fine for my son. But at the same time, I wondered what she had expected me to do when I saw the setting. Was I supposed to turn my brain off and not ask a question about the apparent discrepancy?

Other than this minor flare-up, my son was extremely well taken care of during his visit. But the exchange with the X-ray tech definitely had a chilling effect on me – and I’m pretty comfortable with conflict. And it made me wonder about other patients or family members who question medical providers. If my small question during a routine procedure on a healthy child with a minor injury created irritation and tension, then how much worse is the chilling effect during more extreme circumstances?

Plus – if patients or their loved ones do not speak up, then how many possible medical errors can occur?

The incident made me wonder how many others have had a similar experience. Have you ever faced this dilemma? Did you speak up? Did you decide not to? What happened? 

You can share your story by joining our Patient Harm group on Facebook, or emailing me directly at marshall.allen@propublica.org.

And if you’re a health care provider, I’d love to hear your side of the story, too.


  • Have you or a loved one been harmed in a medical facility? Tell us about it.

  • Have you worked in health care? Tell us what you've observed about patient safety.

I’ve had a similar experience.  I was having a sinus xray done and the tech had me face the board with my back to the xray machine.  She had me put on the protective vest to protect my chest.  However, she had me put it over my chest and not over my back (the side closest to the machine).  I raised the issue and she insisted that the protective vest was positioned correctly.  I insisted that I be given another guard and she complied but her attitude was terrible. I believe that the only people that want us to take more charge of our personal health are those that make mistakes and believe we should have caught their mistakes for them.  MD’s, nurses, techs, etc. all would prefer you just do what you are told.

I think you’re asking the wrong question.  The idea of what you should do when you see a discrepancy isn’t supposed to come up, because you’re not supposed to see the discrepancy.  It’s behind the curtain with the Great and Powerful Oz.  You watch the screen they tell you to watch.

It’s become the corporate way of life.  I can’t tell you how many times I’ve dealt with customer service reps and tried to explain the problem I’m seeing (for example, what I recognize as MPEG-2 artifacts on cable television) only to be treated as if I’m snooping for secret information.

Right now, I’m trying to get Amazon to fix a problem that will get THEM money (they’re having some sort of should-never-happen trouble with secure credit card numbers), and am being told that transactions might fail because the number was typed incorrectly or I need a CVV number, despite the transactions that are succeeding.

There’s a cult of expertise in this country.  I’m credentialled in this field, and you’re not, so you do not dare question my assessments.  You see it in the sleazy way politicians dismiss the concerns of their constituents, corporations refusing to fix obvious problems (if you ever hit a system with a maximum password length, it means they don’t encrypt anything on their side, for example), and the sorts of medical issues you’re talking about here.

At some point, we became the servants of the people we hire, as you can learn from anybody in Staten Island (for example) trying to get money out of their insurance companies for Sandy-related damage.

ALWAYS BE Proactive.  When I took a small child in for an xray, my prescription from family practioner said to take multiple films (to find an object swallowed). 

I explained to the person who came to take us into the room that I wanted to minimize the xray exposure and they were very accomodating.

They dialed back the machine to the lowest setting that would allow them to get an xray and they also only started with 1 xray and we would then look at it to see if it showed what we needed to see.  After seeing the object, I decided one was enough (a 2nd or third would have shown front to back where in the intestines the object was…I was fine with north/south).

[The object was metallic so ideally someone would have used a metal detector first…but apparently ERs and outpatient clinics don’t have metal detectors]

This is reminding me Laurie Anderson’s song “Only and Expert Can Deal with the Problem”. http://lyrics.wikia.c/Laurie_Anderson:Only_An_Expert 

The cult of the expert is deeply ingrained in the American psyche. I’m sure there are studies on this. But I am also reminded of Suzuki Roshi’s teaching: “In the beginner’s mind there are many possibilities, in the expert’s mind there are few.” -Shunryu Suzuki-roshi

This evolution of our role as we move toward consumer-driven healthcare is well worth a healthy examination. Neither the patients, the technicians, the administrators nor the doctors are comfortable having a conversation that questions the authority, opinion or decision of the care provider.

But the more consumers have to pay for their own care, the more they will be inspired and even emboldened to engage. And well they should. It’s to everyone’s benefit. The key will be equipping both sides with the tools and support to make that dialogue timely and productive.

abinico warez

Dec. 4, 2012, 10:36 p.m.

Medical industry kills 200,000 ; injures 1-2 million every year - nuf said.

A basic rule in medical error prevention is that no question about a perceived risk is too stupid to be asked, and no one is too unimportant to ask questions.

I teach communication skills to health professionals at a state university that has many health-professional programs. We have a program in radiography, but its students do not participate. The story suggests that perhaps they should.

I’m an x-ray and CT scan technologist with just under 7 years of experience in various settings, so I thought my thoughts might be helpful.

This is an extremely important topic as patients become more and more involved in their own care.  Radiation exposure is a serious matter and will only get more coverage in the press as time goes on, and while it does seem at times that the dangers can be exaggerated or overblown in many patients’ minds, we as technologists must remember to act compassionately and never let ourselves fall prey to the knee-jerk reaction that discourages perfectly acceptable inquiry and concern by the patient.  We should be honored to impart our knowledge and expertise in clarifying any misconceptions and separating myth from fact.

In this case I think there’s no excuse for the tech getting “snippy”, but I do think it’s important to consider the possibility that the patient’s mother also could have confused an appropriate level of seriousness and concentration for snippy-ness…but this is the challenge my colleagues and I must rise up to.  We must perform our jobs optimally while being mindful that the whole subject of radiation is often a source of fear and the unknown for the patient, and just by being in the medical environment they are in a vulnerable state - especially when we’re talking about pediatric patients. 

Furthermore, there is also the real likelihood that while the patient’s mother thinks the machine was set on “the adult setting”, it very well could have just been the screen displaying that option but not actually set on that parameter.  In other words, you could have the console set to large adult but still change the technique manually lower.  We can’t expect the patient to understand this but we can be tolerant of their concern.

In terms of the comment above about the sinus x-ray shielding:  That tech was definitely wrong.  When you’re facing the board (or “table” or “bucky” or “image receptor”...all interchangeable terms that denote the object that receives the radiation after traveling through the patient) and the x-ray tube is behind the patient, shooting toward their back, of course the shield needs to be on the back side.  Here’s what i bet happened (remember techs are still human and have moments of weakness):  There are usually 3 or 4 different angles we take for sinus images, some of which the patient is facing the x-ray tube, others in which the patient is facing away.  Assuming we’re talking about a waist-hanging shield that only covers one side (some are fully wraparound but those are less common), the tech should have switched the position of the shield between each view but probably got lazy.

To the defense of techs, shielding isn’t always as cut and dry as you’d think.  Certain exams truly don’t require shielding based on the body part and the alignment of the equipment, but often times the tech will still give shielding to the patient so the patient doesn’t think to themselves later “oh no, that tech didn’t shield me!”.  The drawback to this approach is that if a different tech doesn’t shield a patient for the same type of exam where a shield truly isn’t effective, then the patient will be more likely to notice when a shield is not given.

Bottom line:  NEVER hesitate to ask questions.  Just don’t start out with an accusatory tone unless you’re absolutely certain you’re right.  Things are not always what they seem, especially when you’re not the professional in a situation.  I’ve had some patients question me in a tone that is quite arrogant given the fact that they are not trained in radiation physics and related disciplines.  Something that may look cut and dry to you could actually be very nuanced.

Also, there is NEVER an excuse for a tech to give attitude just because a patient is concerned or worried or even just curious.

Anyone who’d like to discuss further is welcome to email me at digs5446 at gmail dot com.  I love my job and I want to be a steward to all concerned.

Dan

Also, a few quick rules of thumb:

Unless you are an immunocompomised person, a child, or a woman who is or may be pregnant, you can get several x-rays over your lifetime with zero permanent harm because your DNA will repair itself after any biological disturbance from ionizing radiation (medical radiation excluding ultrasound which uses sonic radiation and MRI which uses magnetic radiation - both deemed perfectly safe at this point in time).  The key thing to look out for is getting repeated imaging studies on the same body parts in a short period of time.

Also, some parts of the body are much more radiosensitive that others:  the thyroid is one of the big ones.  That is one area more susceptible to the development of cancer and other issues of it is exposed to repeated, high concentration radiation.  Just know that in some exams we cannot shield your thyroid (chest, neck, skull, sinus, and related anatomy) because the shield would be blocking what the radiologist needs to see in order to make a conclusive diagnosis.  In the end all imaging studies are and should be treated as a risk vs. benefit scenario.

And finally, some types of radiology tests are much more radiation intensive that others.  For example, CT scans give literally hundreds of times as much radiation as an x-ray because they need that for the incredible resolution CT provides.  So doctors should order CTs sparingly and not just out of curiosity or laziness.  Just know that some ailments are really best imaged with CT scan so it can often be fully justified and useful.  Better to catch something than not have the CT and let the problem become serious and even life-threatening.  Again, it’s a risk vs. balance thing.

And then you have your standard chest x-ray, which yields about the same amount of radiation as the solar radiation you’d get from flying coast to coast, or living in Denver (high altitude) for a year.  Also, many people who love in older houses in areas where radon gas is prevalent (my homeland of New England being one of them), you’re probably getting much more terrestrial radiation from that radon than you are from any time of x-rays.

Dan

sorry, that should read “man people who *live* in older houses” and “any *type* of x-rays”.

Spell checker isn’t all powerful!

I don’t know what specific question you asked. I think that has a significant impact on how the X-Ray Tech responded to you. You said you “...pointed out the discrepancy” , well, how did you do that? Did you say “Hey, my son’s not an ‘average sized adult’ are you trying to kill him?” or did you say “What does this mean here? Does it effect the test at all?” Those two questions are very different ways of handling the same situation. But, like I said, I don’t know what question you asked so I don’t know if her “chapped hide” was appropriate or not.
I ask lots of questions of medical staff and other professionals but I’ve never had someone respond to me that way. But I know how I ask the questions and I try to be very aware of how I come across.

Dan, I’m the community manager here, and just wanted to thank you for sharing your thoughts. We’d love for you to take a look at our provider questionnaire and see if you have anything to add. It’s the easiest way for us to track providers’ thoughts and contact you down the road: http://www.propublica.org/article/providers-share-your-observations-on-patient-safety

-Blair Hickman

Thanks Blair!

I always get a nasty response when I question(politely) the TSA about the xray machines at the airport and choose to “opt-out.” Not exactly the same subject but I still consider X-rays a medical procedure even if the government doesn’t see them that way in the airports.

Larry, it’s worth pointing out, though, that they’re being paid to deal with you, the patient (and family) is the customer.

I’m a programmer, for example, one of few jobs where people blow off almost any bad behavior under the banner of presumed social ineptness, but there’s still no excuse for getting defensive, even if the question is a curse-laden tirade.  If the issue is that the client is being disrespectful, being obnoxious certainly isn’t going to resolve it.

A reaction like Dan’s is ideal.  It’s like they say in writing, “show, don’t tell.”  Asserting that you know what you’re doing is worthless, whereas Dan clearly does.

I’m with JD Mathews regarding TSA’s use of backscatter x-ray machines. I’m glad they were removed from my home airport, as they unnecessarily slowed screening to provide worse than normal quality of service (not that there is to be said about that). As reported here at ProPublica, there was no means provided to measure the radiation dose given to travelers o operators.

The more I travel, the more I think that Homeland Security is making us believe there’s a terrorist on every corner and bombs in everyone else’s underwear. That’s a sorry joke on us, and a big pork barrel waste of money on corrupt politicians.

An essay in line with the discussion here: it’s by an instructor at Harvard Med and physician at Brigham and Women’s, whose mother experienced a medical error. He had noticed some things weren’t right during her hospital stay, but was conflicted on whether to speak up. “I knew there could be a downside to being too demanding in a hospital,” he wrote.

Whole essay is worth a read: http://m.content.healthaffairs.org/content/31/12/2817.full#sec-1

My issue dealt with a simple day surgery and the type of anesthetic my health provider deemed necessary for the removal of a small growth one of my fingers. They wanted to use a general and I countered with my desire for a local. (A local eliminates the problems, especially with older people like me, of grogginess and lingering confusion - as well as the need for a post surgery “designated driver”.

After some arguing, they finally agreed to do it my way, but I was treated rather poorly as a result, receiving barbed comments about how lucky I was to live in a country with great medical care instead of being subject to third world conditions. The staff attending pre/post surgery patients were caught off balance and seemed somewhat concerned that I was able to leave immediately, proving to me that general anesthetics are the rule there, no matter what kind of procedure is being done, and that I had disrupted their assembly line process.

Just as the local anesthetics used in dental procedures leave patients lucid and capable, I was able to dress myself and walk to my car only moments after the procedure. There I unwrapped enough of the boxing glove sized gauze wrappings they put around my entire hand so I could grab the steering wheel and drive myself home. (A gauze pad and bandaid was all that was actually needed.)

It shouldn’t have taken an argument to accomplish what should be a routine common sense solution for pain control with so many minor surgeries.

As a former EMT now disabled I have run into this situation many times.  I am dismayed sometimes at the treatment I or friends are givenby staff at our local hospitals.  I have no doubt that the x-ray tech mentioned above got snippy, no matter how the question was asked.  Doctors down to techs seem to view with disdain those who would dare to question the proper procedure for a given illness or injury.  This is why we occasionally read of someone getting the wrong limb or body part cut off.  The only reason this situation has improved in the last few years is not because of concern for the patient but concern for being sued over the mistake.  I have made it somewhat of a personal mission for myself to rid myself of those doctors and medical places that seem to be assembly line productions.  Those doctors who show a genuine concern for me as a patient, and there many of those around, despite how it sometimes feels,, are the doctors I want to see again and i will go out of my way to make that happe even if those doctors have a slightly lower level of license than the ones who only look at you and your medical problem as paying for their next sportscar.  One other thing, I saw this current health care crisis of patient care and cost coming a long time ago and it comes down to just plain greed over care.  When medical boards across the country start making a concerted effort to rid the profession of those who have forgotten their oath to ” do no harm,  when that happens is when this health care crisis will finally begin to improve.

I’ve had a similar experience.  I was having a sinus xray done and the tech had me face the board with my back to the xray machine.  She had me put on the protective vest to protect my chest.  However, she had me put it over my chest and not over my back (the side closest to the machine).  I raised the issue and she insisted that the protective vest was positioned correctly.  I insisted that I be given another guard and she complied but her attitude was terrible. I believe that the only people that want us to take more charge of our personal health are those that make mistakes and believe we should have caught their mistakes for them.  MD’s, nurses, techs, etc. all would prefer you just do what you are told.

Uh…copy and paste much, gullfaraz?

I ask questions of everyone - doctors, dentists, opticians, techs, everyone.  If it is during a procedure I’ll usually preface the question with “just out of curiosity…”, but I have a right to ask what they are doing and what they are prescribing.  I asked the same questions regarding my children when I was responsible for them and my parents when I was responsible for them.  If the “professionals” don’t like it they can go get another job where no one cares what they do.

She could have used an adult setting, then adjusted down the mA setting based on your son’s size and the body part she was imaging, which would have lowered the dose.  I hope that is what happened.
I’m an R.T.  We are all supposed to be practicing ALARA (As Low As Reasonably Acheivable) when we chose the radiation dose.

Most units in operation now have AEC (Automatic Exposure Control), which shut off the radiation once the amount needed is detected.  This gives added dose protection.

The technician’s defensive response was a bad sign.  To ask for a second opinion from a supervisor is always appropriate.

I’ll be in contact with you folks at propublica.  Right now, I have both the experience of being a former provider and now unfortunately, a patient.  What I see sometimes in the doctor or hospital setting disturbs me quite a bit, and while thinking about it earlier today, I have stories that I think would be helpful to you in your continueing investigations of this matter.  By the way, kudos to the person who said he always asks questions,  I’ve heard of doctors who are quite appreciative of that because it means the doctor-patient relationship actually improves, on the other hand I have run into doctors and nurses who seem to take the patient asking questions as an affront personally directed at them.  You’re the patient and you have the right to ask those important question, no matter how snippy a doctor or nurse gets.  When I was losing my sight and had to endure 3 surgeries in two months, I was quite appreciative of those doctors who took the time to explain to me exactly what the surgery’s entailed and one doctor even referred me to a mobility and orientation person who would eventually help me learn to live without sight.  On the other hand, I had a problem with a newly installed glaucoma implant and was in quite a bit of pain and very much afraid that the pressure in my eye had gotten very high.  That doctor said that there was no problem, that the glaucoma implant couldn’t have possibly failed, which it had, the pressure in my eye had gone up to 80, normal is around 15 or so, and we ended up having to do emergency surgery to relieve the pressure before the retina completely detached.  That doctor completly ignored my complaints as a patient and it almost cost me not only my sight but the eye itself.  Needless to say, i am no longer a patient of that doctor and any chance i get give a very poor reccomendation of that doctor.  Due to other issues with my eyes i now only see light and shadows but at that time I still had some sight and this doctor didn’t seem to care if i lost it or not.  Thanks to those of you at pro publica who are reporting on these issues and bringing the current state of medicine and medical issues to light.  Shine as big a light as you can on this problem!!

This article is part of an ongoing investigation:
Patient Safety

Patient Safety: Exploring Quality of Care in the U.S.

More than 1 million patients suffer harm each year while being treated in the U.S. health care system. Even more receive substandard care or costly overtreatment.

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